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HomeMy WebLinkAbout0276 FALMOUTH ROAD/RTE 28 (11) �t Sign TOWN OF BARNSTABLE Permit * BMWSTABLE, MASS. 9�iojFO A� Permit Number: Application Ref: 200906150 20070404 Issue Date: 12/1.6/09 Applicant: BORNSTU LIMITED PARTNERSHIP Proposed Use: DEPARTMENT DISCOUNT STORE Permit Type: SIGN PERMIT Permit Fee $ 75.00 Location 276 FALMOUTH ROAD/RTE 28 Map Parcel 293031 Town 14YANNIS Zoning District H g Contractor PROPERTY OWNER Remarks 33 SQ WALL SIGN SHERMAN WILLIAMS PAINTS Owner: BORNSTU LIMITED PARTNERSHIP Address: 297 NORTH ST HYANNIS, MA 02601 r-- { Issued By: PC POST THIS CARD SO THAT IS VISIBLE FROM THE STREET 4 R ( o/J46 11 °Ft�E t Town of Barnstable ToIyAl OF.� ,, ti C�STA�C� Regulatory Services ,, J 9BARNSTABLE, Thomas F. Geiler,Director F~t 25 /; z MASS. E16 p.,A Building Division Tom Perry, Building Commissioner t 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Permit# Building Official approving-___-___---- Application for Sign Permit ____ __ ,________Assessors No._ _ __ Applicant:_r_ �4 n� � - �✓ ���-- --- /, Doing Business As:-,Sj&(j,t21-,s11�1LA _______Telephoue No.--------------- Sign Location a Street/Road: _ L � �'1 _ _ Zoning District:_______ Old Kings Highway? Yes/No Hyannis Historic District? Yes/No Property Owner _ Name: �(2 LF_ o r NS�ei N----------------------Telephone: O�_-)?-S '-31f Address:-o2 kvrF sf -� &,I �I ,fin --------�-----�----��----�-1`�'�'-`--Village:---------------------- Sign Contractor - 4 Name:_-P0gh _ Ssvo c — nee. e�p_TA dpr-_Telephonel--��?p _ -- . - _ -- --- - -----P- ��- atMaihngAddress: o Description Please follow the cover directions.You must have an accurate rendition of sign with dimensions and location. Is the sign to be electrified? Yes/91 (Note:If yes, a wring permit is required) Width of building face 3* ---ft. x 10-__1 g_-_x .10=_-_--_-__ Check one Reface existing sign____or New_Total Sq. Ft. of proposed sign (s) ____ If'you leave additional signs please attach a sheet listing each one with dimensions If refacing an existing sign please provide a picture of the existing sign with dimensions. I hereby certify that I am the owner or that I have the authority of the owner to make this application, that the information is correct and that the use and construction shall conform to die provisions of §240-59 through§240-89 of the Town of Barnstable Zoning Or 'Hance. Signature of Owner/Authorized Agent:__ Date__________ SIGNS/SIGNREQU revised103009 }a Existing Signage To Be Removed And Disposed Of Property 34'-0"Lease Space Ploy ant 125 Samuel Barnet Boulevard v • New Bedford,MA 02745 o 1G^dG^_Y".L.6 1'EUDI SS W RL � 800.544.0961 1 poyantslgns.com r r1* - ° SHERW/N-WILLIAMS PAINTS 0 SHERWIN-WILLIAMS. r 273 Falmouth Road _ L Hyannis,MA C � r Protect:2982 The Sherwin Williams Co. Sales Ed Taylor .. -�...-�., '} r+- a ` — ' ~• ^M t `J ".. Date:11.09.09 a' - Designer.ST �1Storefront Elevation-Existing Storefront Elevation-W/Proposed Si na e Note: �"� Approx Scale:1/B"=1'-0" B Appro. Scale:1/8" This Is an original unpublished drawing created by Poyant Signs, Inc.It is submitted for your personal use in connection with a project being planned for you by Poyant Signs,Inc.It Is not to _ 1 3/4 23'4" be shown to anyone outside your organization,nor Is it to be reproduced,copied or exhibited 'Y in any fashion until transferred. %r Trim Cap 2 D"� �HER WIN WILL1AMS PAISITS Reviaien5: ;!:_ 3/8"Acrylic C SI n Elevation-Front ViewScale:1/4"=1'-0" �s 10 Per-Forated Acrylic Tap Pads Specifications Colors&Materials City=1 33.2 Sq Ft Paint ,¢ New Single Face Externally Illuminated Building Sign r Bronze Tone - s Approved By: ' `Remove&Dispose of Existing Building Sign © PMS 485C;Satin Finish IPA. cfi Letters: Vinyl Date: •3/8"routed acMlc faces painted PMS 485C Blue Arlon k05 -Trim caps painted bronze tone PMS 293C I✓<'� - .Logo: Perfect Match Red Adon N220 - New Building Sign _ Mountin Detail PMS 485C , Not to Scale -3/8"routed acrylic face with first surface applied vinyl graphics ,;'; -Tdm caps painted bronze tone Option A TOWN OF BARNSTABLE BAR_w 404 Ordinance or Regulation WARNING NOTICE Name of Offender/Manager Address of Offender MV/MB Reg.# Village/State/Zip Business Name -5 Hi,'-R4zM �am/p'm, on -' E 20_D Business Address P.. _n5 'Ro" cll�a7 Signature of Enforcing Officer Village/State/Zip ( 'Mew IS Location of Offense Enforcing Dept/Division Offense r)" 4f 0 A LA P�6rt it,tA t r, -5 ( 1 Facts ; This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. � 1 P �4^ Ar i jr erg11 F �O Aff 1 j f �i i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel y Application a00Ct05 l ( / Health Division �O�D�3/1� Date Issued Conservation Division Application Fee 1)0 Planning Dept. Permit Fee J�O Date Definitive Plan Approved by Planning Board V it, �'S Historic - OKH _ Preservation / Hyannis Project Street Address a 19 �}- u Village Owner Address 000 e l� SJ Telephone S'a - ^ �7 5— Permit Request ✓-�n.c '- r�'o �-�- / Square feet: 1st floor: xisting "proposed 2nd floor: existing proposed Total new-4, .� Zoning District Flood Plain Groundwater Overlay Project Valua 2� L&? Construction Type u Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supportin9 documen lion. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) 71 Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highay: ❑X �lo Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: (, Gas ❑ Oil ❑ Electric ❑ Other Central Air: N�Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial �16s ❑ No If yes, site plan review# Current Use G y4st, Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 122ze,-_ ,be Telephone Number Address '�y'7 License # _:r 3 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 4A7"� SIGNATURE DATE a r , FOR OFFICIAL USE ONLY APPLICATION# l DATE ISSUED 3 MAP/PARCEL N0. r • 7 ADDRESS - VILLAGE OWNER �� DATE OF INSPECTION: FOUNDATION 'z FRAME = r INSULATION -; FIREPLACE - ELECTRICAL: ROUGH FINAL <: PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING r DATE CLOSED OUT ASSOCIATION PLAN NO.-,., v �M'..•-s•i-q•� - '?-•�:;[?} ON i epar ]it:-r/l�lQ(plJ� L/ISK a- Qi6S i�tyi�{/}l}1�Lj.S4iasa+ ii.a, ' Y ; � : 600 Washin on Street � .�I b� r Boston,Mass. Dllll Work„�.t- � ers' Com ensadon Insurance davit .. rQE arantxa�rr. //ir ��" ..„�., � ii, /���///��%//// ��/�,,//i., name. S I PPE ISSETT ONS RUC ocaion: 297 North St.: citv Hyannis MA 02601 o�oneft f 5os ) 775-9316 0 I am a homemvtuxperfonnfng all work tnyselL , [ am a sole r mtor and have no one workin in any ca achy 10 din workers' compensation for my employees working on this job. (JR' 01 I am an employer provi � g P com nnv name: Sippewisaett ' .. +y.b,21 .... • .'n ... :•v: war -Y=y:.iF��'•y:'�`Y.:l ._ address- cites Hyannis, MA -026DI _phone#: {508) '775-9316 :- nlfcv*W.CC 50Q254901200 alb ?"- nsurance cn. [] I am a sole proprietor.Genera!coatractor,or 6onneowner(circle one)and have hired the contractors listed below wh. have - the followring workers'ctitnpeasaaon policesr com anv name• .•,, ..�. address' :•: :.x:t . .t'""" ;,, .•.: :. '. 1 '" :?r �'• :... a•: ...tom. 1� .►--.. nil inso nee cm «« company name: address: • Ci—!tv. yam,• .y...pr;.p•�,•. ..••• u.: .: • d....-: .««g:.�«jai.....« ,,.g-,�Cj�--- . rR•:R�;!��•.Y:.io6aati..y -••o �ii• •x�•• ••.np0���w7Waa��:�1'�« "Y•'�, pN• ' n�orance co. Fafhtse sag coretage eegdleed Qadsr o't 2S�►of MGL In eaal-i a"-to thtbnpoaftlon of cebnbw peu-214 eta�etap to StlAO&CO and/or es in the form ors SMp WORK ORDER and a dat.o[SIOLOO-a day.against tqe I mulerataaW that o one Yeses'imprisonment>v weri as dull pto d th.OtbCe of lavestit o bons of the DIA for coverage reHacatton. copy of this statement may be fortrarded to e I do her a ify an site d malt jpe u_ the information provided above is true and correcz Date .11/24/2009 -Signature Mi-cha J { Roberts Pho=# (508) 775-9316 Print nme : . .....;.... .. sot write in this srea to be completed by city or town official omew use only do ..perntitllleense 0 OBullding Department city or town: Qldcensing Board ome b required Melettmen'j Office O check if lmmediate rap Ogtalth Department phone#; QOther contact person: �Ec-rura 9,95?)A) Client#: 16170 2SIPPEWISSETTCO AtCORM CERTIFICATE OF LIABILITY INSURANCE 01/08/09° "' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Agency . ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 973 lyannough Rd., PO Box 1990 Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Associated Employers Insurance Compa Hard Hat Construction;BayPoint,LLC& INSURER B: Sippewissett Construction Corp. INSURER C: 297 North Street INSURER D: Hyannis,MA 02601 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SR kOD'N POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR TYPE OF INSURANCE POLICY NUMBER E(MMIDDrfn DATE(MMIDDNYI GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ POLICY M PE O LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Es accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON-0WNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ ]DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION AND WCC5000549012008 12/07108 12/07/09 XTORY WC LIMIT ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $500 000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $500 000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Suffield Mgmt Corp.etal DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 n_ DAYS WRITTEN 297 North Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Hyannis,MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #55003 LS1 O ACORD CORPORATION 1988 Town of Barnstable Regulatory Services � a,AFNs�!►E�w . Thomas F.Geller,Director . Building Division ��EnnM� ToM3?erry, Buildingcoum3issiouer , 200 Main Street,gyaaab,MA 02601 www.town barustRble.Ina.us Fax: 508-790-6230 ' Office: 508-862-r}038 Property Owner Must . Complete and Sign TMS Section If Using ABuilder by S t u a r t Bornstein ,as Owner of the subject property ` Iy' Mictrael J. Roberts to-act onmybehalfs 'hereby authorize in all _�,tters relative to work authorized bythis building permit application for, 276 Falmouth Road (Route 28) , Hyannis (Barnstable County) , MA 02601 (Address of job) (a.k.a. Hyannis Crossing) 11/24/2009 Sig of Date Stuart A. Bornstein, President, Holly. Mana. Managerupply of Borons�tu, LLC Print I*Tame ' �'l�'• I.� � •�jLC v/O'IId!IYLO�JZG"_'"'""''p�'KVv6ClQdCLCl7.(IQe�6` i ,.. , I k _.• Boafd of Building Regulations and Srarijards Construction Supervisor License f ' r. i L{cee%se::CS. 53861 + �.. , I' tEx Ita ion ',,— I __ — 3/2010 ,.• t T 1601371 F l;gestnction 0U j € 4 I c -:' MI,-HAEL'J ROBE kJ RTS .::;; 181'6 FALMOUTH RD#C6 1_ t` � CENTERCHLCE'MA02�32` a�G Commissioner ( °I Slit c gb k e r { €i ;v [N€WFF t � r3r �r t . € Qf�; i .. �7 ���� ta Rl��M+' .. t l �' 5 ' ja tr .�v� #AA +��'�t}�'. � t,��h ;•.1,+�,.:�e"ta`at � *-•. � �.:. ��fi��3w.'.. { +• rxeY a , i 7 ' zy-'Y<'Y '�Y"'Sa fi a i' .. ~ � '9B• .h CT 36 F��fhx` �'a - �, z� ki fin. 9 y a j 4t-f sr w }} yr t O+.' �§7 1' riF M }' } tir biz -14 kiiV „,� �t-tax„�>. � ��tt•.a ���,;Y i.� „ � € �x:.a �� "�,.Y�'"°`� . .t i F � yir�r, �_a 1111 �s i k.{'y Y€ h hc+�$•. AMP HYANNIS MA 10-09-09 HALF 140'- CCRCU TSB 60' PIGTAILED FOR EX7 SIGN OFT'ICE OjFICE C CIRCUIT _ CDTCUIT A I DUPLEX' 12' F \C natw'.� HERPROOF DUPLEX I 87'A.F.F. 87'AFF. 1 vKX - FOR BLACK BOX Tw SALES AREA K 20 AMP DEDICATED/ q� Lg/ BUZZER FOR ID DOM LEAVE ATrE 7� Fi OVER D0013R CONDUIT FOR LAN VIBE 7 }r M 4'AF F. CIRCUIT G zo i a nuPLEx20 AMP CIRCUIT X gy Ir AFF. SAGM DEDICATED DOOR GLASS 20 AMP VDGM CMCUIT D877''AFF.ABOVE �7 � FDR OPEN SIGN COFFEE BAR VCIRCUIT CIRCUIT TWW $� �y�5 � W\� T NCLOSER DUPLEX \ DUPLEX /07'A.F.F. 97'AF\ � a Tnrroo A!G RQf RD71 66' cwzc GAFF. wT� EXHIBIT "C" 1 OF 3 PAGES ,} ry Massachusetts Department of Environmental Protection L71- Bureau of Waste Prevention • Air Quality 100098239 �� Decal Number .._..........__.- BWP AQ 06 Notification Prior to Construction or Demolition Important: A. Applicability When filling out pp y forms on the computer,use only the tab key A Construction or Demolition operation of an industrial, commercial, or institutional building,or to move your residential building with 20 or more units is regulated by the Department of Environmental Protection cursor-donot use the return (DEP), Bureau of Waste Prevention-Air Quality Control Regulations 310 CMR 7.09. Notification of key. Construction or Demolition operations is required under 310 CMR 7.09 (2)ten (10)days prior to any work being performed.The following information is required pursuant to 310 CMR 7.09. B. General Project Description 1. a. is this facility fee exempt-city,town, district, municipal housing authority, owner-occupied Instructions residence of four units or less?❑Yes Z✓ No 1.All sections of b. Provide blanket decal number if applicable: Blanket Decal Number this form must be completed in order 2 FBCIIIt Information: to comply with the y Department of HYANNIS CROSSING Environmental Protection a.Name notification 1276 FALMOUTH ROAD requirements of b.Address 310 CMR 7.09 H annis MA 02601 � c. i /Town d.Sta a e.Zip Cod _--__,•._ ____ (508)775-9316 f.Tele hgn_g Number are de and a nsion .E-mail Address(optional) 5,000 1 h.Size of Facility in Square Feet i.Number of Floors j.Was the facility built prior to 1980? Yes ✓] No k. Describe the current or prior use of the facility: RETAIL STORE I. Is the facility a residential facility? Yes No _o m. If yes, how many units? Number of Units �° 3. Facility Owner: �N BORNSTU LLC 10 a.Name �a 1297 NORTH STREET b.Address HYANNIS A 02601 �co C.Cit !Town d.State e.ZiD Code �o (508)775-9316 _ f.Tele hone Number area code and extension__ _ g E-mail Address o tiona,,l)_•,,,•,•„_, MICHAEL ROBERTS Q h.Onsite Manager Name ag06.doc•10/02 BWP AQ 06-Page 1 of 3 Y Massachusetts Department of Environmental Protection Bureau of Waste Prevention •Air Quality 100098239 '1 Decal Number BWP AQ 06 ....._...._......... Notification Prior to Construction or Demolition General Statement:if B. General Project Description cont. asbestos is found during a 4. General Contractor: Construction or Demolition 'MICHAEL ROBERTS operation,all responsible parties a.Name must comply with 1815 FALMOUTH ROAD,APT C-6 310 CMR 7.00, b.Address 7.09,7.15,and CENTERVILLE MA 02632 Chapter 21 E of the General Laws of c.City/Town d.State e.Zip Code the Commonwealth. (508)962-7792 This would include, f.Tele hone Number area code and extension .E-mail Address o tional but would not be MICHAEL ROBERTS limited to,filing an asbestos removal h.On-site Manager Name notification with the Department and/or a notice of release/threat of C. General Construction or Demolition Description release of a hazardous substance to the 1. Construction or demolition contractor: Department,if applicable. IMICHAEL ROBERTS a.Name 1815 FALMOUTH ROAD,APT C-6 b.Address CENTERVILLE MA 02632 c.City/Town d.State e.Zip Code (508)962-7792 f.Telephone Number area code and extension .E-mail Address(optional) MICHAEL ROBERTS h.On-site Manager Name 2. On-Site Supervisor: MICHAEL ROBERTS On-Site Supervisor Name 3. Is the entire facility to be demolished? ID Yes 21 No N -0 4. Describe the area(s)to be demolished: �0 TWO INTERIOR WALLS. O 0 5. If this is a construction project, describe the building(s) or addition(s)to be constructed: � ONE NEW OFFICE SPACE,ONE NEW DIVIDING WALL. _0 C7 �Q ag06.doc-10/02 BWP AQ 06•Page 2 of 3 t"v Massachusetts Department of Environmental Protection ■ Bureau of Waste Prevention • Air Quality 100098239 •, Decal Number BWP AQ 06 Notification Prior to Construction or Demolition C. General Construction or Demolition Description (cont.) 6. a. If this is a demolition project,were the structure(s)surveyed for the presence of asbestos containing material (ACM)? ❑ Yes ❑ No If yes,who conducted the survey? usxevo c.Division of Occupational Safety Certification Number 12/05/2009 � 112130/2009 7. Construction Or Demolition: a.Start Date(mm/dd/yyyy) b.End Date(mm/ddlyyyy) 8. a. For demolition and construction projects, indicate dust suppression techniques to be used: ❑ seeding ❑ paving b. If other, please specify: ❑ wetting [ shrouding ❑ covering ❑✓ other JINTERIOR WORK 9. For Emergency Demolition Operations,who is the DEP official who evaluated the emergency? a.Name of DEP Official b.Title c.Date mm/dd/ of Authorization d.DEP Waiver Number D. Certification I certify that I have examined the MICHAEL ROBERTS �o above and that to the best of my a.Print Name �o knowledge it is true and complete. IMICIHIAEL ROBERTS The signature below subjects the b.Authorized Signature —N signer to the general statutes P�osiion T MANAGER o regarding a false and misleading E. e �o statement(s). 1BORNSTU LLC d.Re resentin -� 11124/2009 -(p e.Date(mm/dd/yyyy) �Q ■ ag06.doc•10102 BWP AQ 06•Page 3 of 3■ CHARGE ACCOUNT DATA To be completed by bookkeeper Payable To: S Company Payable From: Amount. U 0 To be completed by credit card holder Credit Card Used: 1111.3M- Last 4 Digits of Account# Being Used: Back of card code number given? (circle one): Yes -No Phone # to Company Charge: C57v('iC�IL "- 0 0� P an p Y Accepting P Person Contacted: ► -� Date Charged: Must be returned to bookkeeper by noon of date Signature: Comments: i wp i� l 1 caw ATTACH ALL INVOICES CHARGED TO THIS SHEET eDEP - MassDEP's OnlineFiling System Page J of 1 MassDEP Home i Contact i Feedback I Tour i Privacy Policy MassDEP's Online Filing System Usemame:CHRISTYMORRIS Nickname:HOLLYMANAGEMENT My eDEP; Pormsog; My Profile®, Help Receipt Forms Signature Payment Receipt Summary/Receipt print receipt Exit Your submission is complete. Thank you for using DEP's online reporting system. You can select"My eDEP"to see a list of your transactions. DEP`Transaction ID: 276404 Date and Time Submitted: 11/24/2009 10:48:18 AM Other Email : Form Name: AQ 06 -Construction/Demolition Notification Payment Information DEP code: 42207 Date: 11/24/2009 10:46:33 AM Amount($): 85 Payment Detail: MORRIS CHRISTY--AccountType--AccountNumber ****6213 Confirmation Number: Contractor Contractor Number Name Address, , Supervisor Project Monitor Lab My eDEP MassDEP Home i Contact j Feedback Tour I Privacy Policy MassDEP's Online Filing System ver.9.0.0.0©2008 MassDEP https://edep.dep.mass.gov/Pages/PrintReceipt.aspx 11/24/2009